Transcript Multimodal Treatment of Hyperactivity Disorders

Multimodal Treatment of
Hyperactivity Disorders
Professor Peter Hill
London
Multimodal treatment
Total treatment of the whole child
Two initial diagnostic issues
• Differential diagnosis
Is this actually ADHD or something else?
• Co-morbidity
What else is going on as well as ADHD?
In my hyper-specialist clinic at
Great Ormond Street Hospital for
Children, London
Cases of ‘ADHD’ referred for re-evaluation from
all over the UK by other specialist child
psychiatrists
In this clinic
In the last 100 cases seen in 2002
18 were confirmed as ADHD only
37 were ADHD and something else
45 looked like ADHD but were not
Of these 45
(Looked like ADHD but on detailed
examination, did not meet diagnostic criteria for
it)
10
8
5
4
4
3
autistic spectrum/PDD
anxiety
attachment disorder
global learning disability (IQ<50)
conduct disorder only
Tourette’s syndrome
Of these 45
(continued)
3
3
2
2
developmental language disorder
primary sleep problem
impaired auditory memory only
episodic hyperactivity
-Kleine-Levin syndrome
-cyclothymic mood disturbance
1 frontal lobe damage
Co-morbidity for developmental
disorders
dyslexia
ADHD
n=48
8
7
19
10
23
dyspraxia
26
Kaplan B et al 1998
Co-morbidity for other disorders
• 40-70% have conduct or oppositionaldefiant disorder
• 30-40% have anxiety disorders
• up to 30% eventually show mood disorder
• Increased rates of
– tic disorders
– drug misuse
Associated issues
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Family stress and breakdown
Educational underachievement
Low self-esteem
Relationship failure
ADHD in other family members
In other words
• Full clinical assessment absolutely
necessary
– For differential diagnosis
– For assessment of co-morbid conditions
– To recognize impairment and associated
problems (“the burden of ADHD”)
Also necessary
• To establish a baseline of clinical features
and impairments so that treatment can be
evaluated
Protocol approach
• To ensure thoroughness
• Should be possible to audit - to examine
what went on in each case
• Intended for first contact with specialist
service
Boxes are ticked when task is
completed
Not there for data entry
Assessment 1.
• Baseline
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presenting complaints
ADHD symptoms
academic achievement
social relationships
parental attitudes
Assessment 2. Sources
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Parental interview
Parental questionnaire
Child interview
Teacher questionnaire
Teacher report
Assessment 3. Coverage
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Current symptom review
Developmental history
Family history
Medical history
Medication history
Assessment 4.
Physical assessment
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Growth chart
Head circumference
Hearing
Co-ordination
Assessment 5.
Psychometric assessment
• Verbal (BPVS, WISC, BAS)
• Non-verbal (Matrices, WISC, BAS)
• Reading
Assessment 6.
Check co-morbidity
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Antisocial behaviour problem
Emotional disorder
Tic disorder
Pervasive developmental disorder
Specific scholastic skills problem
Motor planning problem
Self-esteem problem
Treatment practice
Provide information.
Establish basic parental
and classroom handling
practices.
Fulfil basic criteria for
medication?
yes
Medication protocol
no
Few foods diet
Treatment practice 1
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Information to parents
Information to child
Letter to school
Letter to GP and school doctor
Best treatment practice 2.
Basic handling practices
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Appropriate expectations
Positive parental attending
Effective communication of rules
Contingency management
Conditions for stimulant
medication
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Diagnosis recorded
Parents accept
School will co-operate
Normal heart and blood pressure
Seizure-free or stable epilepsy
Not Tourette’s syndrome (?)
Growth satisfactory
No household member with substance
misuse or eating disorder
Basic principle of medication protocol
Titration of dose against
• symptom relief
• academic and social achievement
• side-effects
Medication 1.
b
• Rating scale to parents
• Rating scale to teacher
• Side-effects list to parents
Collect at or just before
• 2-3 weeks after baseline rating (b)
• 4-6 weeks ditto
• 6-9 weeks ditto
Times will vary according to school term
b=baseline
2w 6w 9w
Medication 2.
• Methylphenidate 5, 5, 5 for 2-3 weeks
• Methylphenidate 10, 10, 5 for 2-3 weeks
• Methylphenidate 15, 15, 5-10 for 2-3 weeks
Can add promethazine/clonidine/trazodone/
melatonin as evening dose
Medication 3.
If no response to methylphenidate
Continue fortnightly questionnaires and review
• Dexamphetamine 2.5, 2.5, 2.5
• Dexamphetamine 5, 5, 2.5
• Dexamphetamine 7.5, 7.5, 2.5-5
Can add
promethazine/diphenhydramine/clonidine/trazodo
ne/melatonin as evening dose
Medication 4.
If no response to dexamphetamine
Continue fortnightly questionnaires and review
• Imipramine 25 / day (single or divided)
• Imipramine 50 / day
Medication 5.
• If response, continue, reviewing personally
no less frequently than 6 monthly with
growth chart
• Discontinue medication at 12 monthly
intervals to test requirement
• If no response, consult tertiary centre
Combinations
Protocol uses
• psychological treatment for all, provided
through parents (makes assumption that this
is justified though MTA results question
this)
• diet only if medication not acceptable
But
• What if diet not acceptable?
– Can use cognitive-behavioural approach more
intensively
• What about school?
– Needs active liaison and agreed management strategies
• for classroom and playground behaviour
• for academic performance
• for self-esteem
What else?
Use of both CBT for associated emotional
and behavioural problems (MTA reanalysis)
Taking the long view (American Academy
of paediatrics guidance)
Examining the effect of
medication (mainly MPH) on
non-core psychological features
• Does not alter locus of control (Horn et al 1991)
• Improves parent-child and child-child interactions
(Schachar et al 1987; Whalen et al 1989))
• May increase self-esteem (atomoxetine: Swenson
et al 2001)
• Reduces aggression (Taylor et al 1987)
• Increases academic performance (Pelham et al
2002)
Hard work?
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Full assessment of child
Multiple baseline interventions
Full involvement of family
Inter-agency liaison, especially school
Probably an argument for
- Specialist clinics
- Two levels of specialist service
Worthwhile?
• For child and family now
• For adulthood
– Note that most of the poor outcomes in adult life are
because of co-morbid disorder, educational failure,
relationship failure and occupational failure
• Need therefore to take broadest possible view of treatment
a multimodal or total
treatment approach
effectiveness -